A Physiatric Approach to Falls and Fall Prevention Brad Steinle, M.D. January 16, 2009

Scope of the Problem Falls are the leading cause of fatal and nonfatal injuries to older people in the U.S. More than 1/3 of adults over the age of 65 years fall each year. 323,884 hip fractures occurred in 2003 in the U.S. Between 18-33% of older hip fracture patients die within 1 year of their fracture.

Falls are the leading cause of fatal and nonfatal injuries to older people in the U.S.

More than 1/3 of adults over the age of 65 years fall each year.

323,884 hip fractures occurred in 2003 in the U.S.

Between 18-33% of older hip fracture patients die within 1 year of their fracture.

Scope of the Problem Others sustain soft tissue injury, upper limb fracture, subdural hematoma. Over $20 billion spent in medical costs annually for the treatment and complications associated with falls. Any where to 25 to 75% previously independent seniors lose independence or fail to return to previous level of independence.

Others sustain soft tissue injury, upper limb fracture, subdural hematoma.

Over $20 billion spent in medical costs annually for the treatment and complications associated with falls.

Any where to 25 to 75% previously independent seniors lose independence or fail to return to previous level of independence.

Falls Tend to be Multifactorial Intrinsic Factors Medical conditions Vision changes Age-related changes Extrinsic Factors Medications Environment Improper (lack of) use of assistive devices

Intrinsic Factors

Medical conditions

Vision changes

Age-related changes

Extrinsic Factors

Medications

Environment

Improper (lack of) use of assistive devices

Medical Conditions Neurologic Stroke Parkinson’s Multiple Sclerosis Neuropathies Myopathies Dementia Depression Hydrocephalus Polio (Post-Polio Syndrome) Medical Cardiac Diseases Osteoarthritis Osteoporosis Cataracts Macular Degeneration Diabetes Joint Replacement

Neurologic

Stroke

Parkinson’s

Multiple Sclerosis

Neuropathies

Myopathies

Dementia

Depression

Hydrocephalus

Polio (Post-Polio Syndrome)

Medical

Cardiac Diseases

Osteoarthritis

Osteoporosis

Cataracts

Macular Degeneration

Diabetes

Joint Replacement

Normal Consequences of Aging Neurologic Increased reaction time Decreased righting reflexes Decreased proprioception Vision Changes Decreased accommodation & dark adaptation Decreased muscle mass

Neurologic

Increased reaction time

Decreased righting reflexes

Decreased proprioception

Vision Changes

Decreased accommodation & dark adaptation

Decreased muscle mass

Age-Related Changes with Gait Slower gait (Slower gait associated with increased falls). Decreased stride length and arm swing. Forward flexion at head and torso. Increased flexion at shoulders and knees. Increased lateral sway.

Slower gait (Slower gait associated with increased falls).

Decreased stride length and arm swing.

Forward flexion at head and torso.

Increased flexion at shoulders and knees.

Increased lateral sway.

Loss of Mobility Dysmobility and falling closely related. 15% of those over 65 have trouble walking. 1/4 men and 1/3 women over age 85 have difficulty with walking. 2/3 of people in hospital or NH unable to ambulate without assistance.

Dysmobility and falling closely related.

15% of those over 65 have trouble walking.

1/4 men and 1/3 women over age 85 have difficulty with walking.

2/3 of people in hospital or NH unable to ambulate without assistance.

Medications Fall risk increases with 4 or more medications. Sedative-hypnotics, especially long acting benzodiazepines, increase falls. Small association between most psychotropics and falls. SSRIs and TCAs both increase falls. Weak association between Type 1A antiarrythmics, digoxin, diuretics, and falls. Antihypertensives. Hypoglycemic agents.

Fall risk increases with 4 or more medications.

Sedative-hypnotics, especially long acting benzodiazepines, increase falls.

Small association between most psychotropics and falls.

SSRIs and TCAs both increase falls.

Weak association between Type 1A antiarrythmics, digoxin, diuretics, and falls.

Antihypertensives.

Hypoglycemic agents.

Extrinsic Factors Environmental Factors: Poor lighting Unsafe stairways Irregular floor surfaces

Environmental Factors:

Poor lighting

Unsafe stairways

Irregular floor surfaces

Extrinsic Factors Some patients will only have safe gait with an assistive device. Walkers Canes Ankle-foot orthoses

Some patients will only have safe gait with an assistive device.

Walkers

Canes

Ankle-foot orthoses

Most common risk factors in 16 studies Muscle weakness. History of falls. Gait deficit. Balance deficit. Use of assistive device. Visual deficit. Arthritis. Impaired ADL. Depression. Cognitive impairment. Age > 80 years. Guidelines for the prevention of falls in older person. JAGS 2001;49:664-672.

Muscle weakness.

History of falls.

Gait deficit.

Balance deficit.

Use of assistive device.

Visual deficit.

Arthritis.

Impaired ADL.

Depression.

Cognitive impairment.

Age > 80 years.

Guidelines for the prevention of falls in older person. JAGS 2001;49:664-672.

Evaluation - History Where did you fall – home, work, outside, sidewalk? When did you fall – day/night, lights on/off? Why did you fall – dizzy, lightheadness, trip, loss of consciousness, pet? Have you fallen before? How many times? Do you use a walker, cane – if so, did you fall with the device? Did you hurt anything? Try to confirm with spouse or family member.

Where did you fall – home, work, outside, sidewalk?

When did you fall – day/night, lights on/off?

Why did you fall – dizzy, lightheadness, trip, loss of consciousness, pet?

Have you fallen before? How many times?

Do you use a walker, cane – if so, did you fall with the device?

Did you hurt anything?

Try to confirm with spouse or family member.

Evaluation - History Review past medical history – any history of stroke, Parkinson’s, diabetes, CAD, osteoarthritis? Review medications – focus on anything newly added. Alcohol history – if suspected how much; shoot high. Review exercise, therapy history.

Review past medical history – any history of stroke, Parkinson’s, diabetes, CAD, osteoarthritis?

Review medications – focus on anything newly added.

Alcohol history – if suspected how much; shoot high.

Review exercise, therapy history.

Examination General – check sitting and standing BP. Neuromuscular: Strength Proprioception Rombergs Gait Skeletal – evaluate feet; knees, back, posture.

General – check sitting and standing BP.

Neuromuscular:

Strength

Proprioception

Rombergs

Gait

Skeletal – evaluate feet; knees, back, posture.

Examination Skeletal Kyphosis Valgus and varus deformity of the knees. Pronated foot

Skeletal

Kyphosis

Valgus and varus deformity of the knees.

Pronated foot

Examination Proprioception testing especially important if history of neuropathy. Romberg’s test Increased sway with eyes – think cerebellar. Eyes closed – Posterior column abnormality.

Proprioception testing especially important if history of neuropathy.

Romberg’s test

Increased sway with eyes – think cerebellar.

Eyes closed – Posterior column abnormality.

Examination Strength Arms – shoulder abduction/flexion, elbow flexion/extension, grip. Legs – hip flexion/extension, knee flexion/extension, ankle dorsi-/plantar flexion; check hip abductors if dorsiflexors weak to differentiate proximal versus distal problem. Check plantar flexion with calf raises.

Strength

Arms – shoulder abduction/flexion, elbow flexion/extension, grip.

Legs – hip flexion/extension, knee flexion/extension, ankle dorsi-/plantar flexion; check hip abductors if dorsiflexors weak to differentiate proximal versus distal problem.

Check plantar flexion with calf raises.

Examination Observe sit to stand transfers Slow or fast Any stumbling? Modified Gower’s

Observe sit to stand transfers

Slow or fast

Any stumbling?

Modified Gower’s

Examination Have patient do single leg stance. Should be able to maintain balance for at least 10 seconds. Have patient do tandem stance. Should be able to maintain balance for at least 10 seconds.

Have patient do single leg stance.

Should be able to maintain balance for at least 10 seconds.

Have patient do tandem stance.

Should be able to maintain balance for at least 10 seconds.

Examination Observe Gait – not just in exam room. Have patient do tandem gait, toe and heel walk. Trendelenberg – “Mae West” Antalgic – osteoarthritis. Steppage – weak dorsiflexors; excessive hip flexion. Slapping gait – decreased proprioception; weak dorsiflexors. Shuffling gait – Parkinson’s. Observe posture – kyphosis; flexed hips.

Observe Gait – not just in exam room. Have patient do tandem gait, toe and heel walk.

Trendelenberg – “Mae West”

Antalgic – osteoarthritis.

Steppage – weak dorsiflexors; excessive hip flexion.

Slapping gait – decreased proprioception; weak dorsiflexors.

Shuffling gait – Parkinson’s.

Observe posture – kyphosis; flexed hips.

Treatment If polypharmacy, look at reducing meds. Decrease use of sedative agents.

If polypharmacy, look at reducing meds.

Decrease use of sedative agents.

Treatment Environmental Get rid of the throw rug. Rails for steps. Use walker if needed. Night lighting.

Environmental

Get rid of the throw rug.

Rails for steps.

Use walker if needed.

Night lighting.

Treatment Physical Therapy Be specific with orders – if a strength problem; work to improve – ask therapist to focus on functional strength (closed-kinetic chain exercises). If a balance problem; look for programs that can focus on balance (can be found in vestibular rehabilitation programs). Need plan to continue program in the community.

Physical Therapy

Be specific with orders – if a strength problem; work to improve – ask therapist to focus on functional strength (closed-kinetic chain exercises).

If a balance problem; look for programs that can focus on balance (can be found in vestibular rehabilitation programs).

Need plan to continue program in the community.

Balance Master Training

Treatment Community-based programs Tai Chi. Regular walking programs. Aquatic exercise programs. Resistance training programs – focus on functional movements (leg press).

Community-based programs

Tai Chi.

Regular walking programs.

Aquatic exercise programs.

Resistance training programs – focus on functional movements (leg press).

Resistance Training

Cardiovascular Exercise

Tai Chi

JC is a 61 year old male with a 6 year history of Parkinson’s. Has lived alone and has had increased falls over the last 6 months. Admitted to SLH with “Failure to thrive.” Case #1

JC is a 61 year old male with a 6 year history of Parkinson’s.

Has lived alone and has had increased falls over the last 6 months.

Admitted to SLH with “Failure to thrive.”

Was evaluated by neurology and medication was switched from ropinirole to carbidopa/levadopa and admitted to the rehab unit for therapy and medication adjustment. Over the next ten days, he went to moderate assist for transfers and unsteady gait to ambulating safely without cane or walker. He stated he hadn’t functioned this well in 2 years. Case #1 Continued

Was evaluated by neurology and medication was switched from ropinirole to carbidopa/levadopa and admitted to the rehab unit for therapy and medication adjustment.

Over the next ten days, he went to moderate assist for transfers and unsteady gait to ambulating safely without cane or walker.

He stated he hadn’t functioned this well in 2 years.

Case #2 DK is 58 year old female who was referred for stumbling gait and several falls walking up steps. Was evaluated and found to have weak dorsiflexors. Electrodiagnostic study showed idiopathic peroneal neuropathy.

DK is 58 year old female who was referred for stumbling gait and several falls walking up steps.

Was evaluated and found to have weak dorsiflexors.

Electrodiagnostic study showed idiopathic peroneal neuropathy.

Case #2 Continued She was referred to orthotist for fitting with bilateral ankle-foot orthoses and sent to therapy for gait training. She has had not further falls.

She was referred to orthotist for fitting with bilateral ankle-foot orthoses and sent to therapy for gait training.

She has had not further falls.

Case #3 PJ is a 69 year old female who was referred for difficulty with walking and several falls. She had history of polio as a child and had left foot drop but had not required bracing. Strength exam revealed the left leg to have weakened hip flexors (3/5) which was new; weakened knee extensor (3/5) and dorsiflexors (1/5).

PJ is a 69 year old female who was referred for difficulty with walking and several falls.

She had history of polio as a child and had left foot drop but had not required bracing.

Strength exam revealed the left leg to have weakened hip flexors (3/5) which was new; weakened knee extensor (3/5) and dorsiflexors (1/5).

Case #3 Continued She was diagnosed with post-polio syndrome. Her hip flexors had weakened and she had more difficulty clearing the left foot. She was convinced to be fitted and wear a AFO. She was referred to physical therapy and use of a single point cane was recommended. She has had no further falls since using the AFO and SPC.

She was diagnosed with post-polio syndrome. Her hip flexors had weakened and she had more difficulty clearing the left foot.

She was convinced to be fitted and wear a AFO.

She was referred to physical therapy and use of a single point cane was recommended.

She has had no further falls since using the AFO and SPC.

Case #4 SM was a 79 year old male who was referred for evaluation he had three falls in the past months. History revealed no recent changes. He had a right TKA 2 years ago. Had a h/o CAD, HTN. Exam revealed mildly tightened hip flexors, but normal strength and sensation. Gait mild forward flexion of the trunk. Single leg stance was 8-9 secs on each foot.

SM was a 79 year old male who was referred for evaluation he had three falls in the past months.

History revealed no recent changes. He had a right TKA 2 years ago. Had a h/o CAD, HTN.

Exam revealed mildly tightened hip flexors, but normal strength and sensation. Gait mild forward flexion of the trunk. Single leg stance was 8-9 secs on each foot.

Case #4 Continued He didn’t have a specific diagnosis but was referred to physical therapy for “Gait Disturbance”and “Personal history of Falls.” He underwent aggressive stretching to the hip flexors, lower limb strengthening and Balance program. He was discharged with a home exercise program. He has had no further falls.

He didn’t have a specific diagnosis but was referred to physical therapy for “Gait Disturbance”and “Personal history of Falls.”

He underwent aggressive stretching to the hip flexors, lower limb strengthening and Balance program.

He was discharged with a home exercise program.

He has had no further falls.

Questions (True/False) Decreased usual walking speed in the elderly is associated with decreased risk of falls. (True/False) Most falls in the elderly have a single, identifiable cause. (True/False) Single leg stance testing can be an easy and effective way to assess risk of falls.

(True/False) Decreased usual walking speed in the elderly is associated with decreased risk of falls.

(True/False) Most falls in the elderly have a single, identifiable cause.

(True/False) Single leg stance testing can be an easy and effective way to assess risk of falls.